"There are also some other special considerations with Andy," Susannah began. "Andy wets the bed. He fears punishment for it. Whenever it happened, his father forced him to sit, for hours, on a wet sheet. He would then force him to spend the next night standing in the bathroom. He was also beaten and his genitals were burned."

The staff heard anger in Susannah's voice as she continued. "Andy's enuresis is not only nocturnal. It happens during both daytime naps and overnight. If it should happen when he is out, please react casually and reassuringly. He hasn't experienced any flashbacks over the punishments he received for it, but he does become frightened and sometimes expects to be punished. You may notice he will not want to get out of bed. He expects to have to sit on the wet sheets. Just explain to him that he is in the hospital and he is safe and we don't punish children for wetting the bed or for any reason. He will usually allow his clothes or pajamas to be changed. He sometimes wants only Sam to assist him. Mark, Steve, Angelo, Don, he may become frightened to have men only helping him. If he starts to become agitated, please ask one of the female nurses or techs to assist you. As far as bathing any of them goes you have to always be on the lookout for any seizure activity and be ready to hold their head above the water or, if possible, remove them from the tub."

The new staff members shook their heads at the horror of what has been done to this patient.

"Another thing." Susannah addressed this to all the staff, current and new. "Because of the phenytoin, very close attention must be paid to oral hygiene. I would like them all to be instructed in proper flossing techniques. They will probably all need assistance with it. Some of them are experiencing hand tremors and that might make it very difficult. I would like their teeth brushed three times a day, whether or not they've eaten. All the children get gold stars or stickers, according to their preference, placed on their poster board, under their name, when they have successfully completed their ADLs. They are usually very compliant."

"I see there is an infant alter," Janet observed.

"Yes there is. We call him The Baby. He is approximately five months old. He cannot walk or sit up by himself. He is to be bathed in bed. He's preverbal. I have never been able to, successfully, get Todd or any alter to the front when he is out. So, we have to wait for him to go inside on his own. He usually only comes out when Todd is completely overwhelmed. That brings me to another very important point. If The Baby comes out, you will probably notice he likes to roll over on his stomach. He is the only one, to date, who tolerates that position. Because of the sexual abuse, none of the other alters or Todd are ever to be placed in a prone position for any reason, unless I order it."

Susannah once again referred to her notes and checked off the next item for discussion. "I want to address the use of seclusion and mechanical, physical and chemical restraints." Susannah realized that since some of the new staff was from Chicago, she had to get very specific about the use of seclusion and restraints in Pennsylvania. She also had to make sure that they understood, specifically, what types she considered therapeutic and what types were not considered therapeutic, in this case. "First of all, seclusion is never to be used with Todd. We don't use it at this facility at all, on any unit. Pennsylvania has some of the strictest laws in the nation in regard to how the mentally ill are treated, especially concerning restraints, and I do agree with them. Here, we basically follow the guidelines set by the state hospitals, which act in accordance with the Joint Commission on Accreditation of Healthcare Organizations and the Health Care Financing Administration."

"There have been many changes in regard to restraints recently haven't there?" Don asked.

"Yes. JCAHO and HCFA have set down many changes. Pennsylvania has had most of those changes in place for some time now. Our Deputy Secretary of Mental Health, Charles Curie, has said that 'the use of seclusion and restraint is symptomatic of treatment failure.' In some cases it's contraindicated toward the goal of recovery. Some facilities across the nation were found to be overusing restraints. In some cases, they were being used almost punitively. As soon as the patients showed any signs of escalating, they would be put in a restraint without any attempt being made at less invasive techniques. It is very important to use restraints in a way that is considered therapeutic for each particular patient. In Todd's case, he was sexually and physically abused. He was left alone in a trunk and in a storage shack and in his basement for extended periods. He was sometimes tied up with rope, clothing, belts, even towels and other common items. We also have to take his epilepsy into consideration."

"Is it true that mechanical restraints are prohibited in Britain?" Mark asked.

Susannah was happy to know that her staff was informed. "Yes, it's true. Ideally, a restraint free unit is the goal and many facilities are striving for that. There certainly has been a great reduction in the use of mechanical restraints in this state and many others across the nation. Unfortunately, for the safety of the patient and the staff, I do believe that they are sometimes necessary. As far as Todd goes, mechanical restraints are to be avoided, except for the most extreme conditions . . . meaning . . . talk, de-escalation techniques, physical restraint and sedation are not helping and he is in danger of harming himself or others. There have been times when even heavy sedation has not calmed him. Only four or five point restraints with buckles, never locks, are to be used. Though some facilities in Pennsylvania still use them, the following mechanical restraints are not considered therapeutic in most facilities and we do not use them here. They are . . . blanket . . . wraps . . . full sheet . . . net . . . body bag . . . and camisole. If mechanical restraints do become necessary, the crisis bag is kept at the nurses station. The only alter we ever use any other kind of mechanical restraint on is The Baby. When The Baby comes out we place him in a geri-chair and use a shoulder vest and pelvic belt to keep him from toppling out of it. A Posey vest does not give him the support he needs. We keep him in the chair for an hour then alternate with an hour of bed rest and if he's awake, back to the chair. We do this during the day only."

Susannah paused while her staff took notes. She then continued. "Todd's body is thin and weak and you will find it is not as difficult to contain him or even to contain Pete as it might be with other patients of his age and height. However, once that adrenaline starts pumping, it can still be difficult. If it becomes necessary to restrain him, we usually use five to eight staff members to assist in it, depending on who's out and how violent they have become. We take a couple of seconds before every physical and mechanical restraint and make very sure everyone knows which limb they are responsible for. I usually take the head and do verbal communication with him. Todd is always on one-to-one, but I want two staff members at his bedside, at all times, during a mechanical restraint. In the event of a seizure those restraints must come off immediately."

"Is he spoken to during a restraint?" Janet asked.

"Yes. If he's awake you can comfort him verbally and with a cool washcloth. He is to be documented every fifteen minutes for the need to continue or discontinue the restraint and checked for circulation. At one hour, he is to be released from one restraint at a time and given range of motion to that extremity before it's placed back in the restraint. He is to be offered a bedpan or urinal for elimination, something to drink, a chance for some ADLs . . . have his teeth brushed . . . rinse his mouth with mouthwash . . . things that might increase his comfort level. His vital signs are to be done at that time as well. Now, as far as debriefing goes . . . it is mandatory that the staff and patient debrief after a restraint. However in this case, the one who goes into a restraint is usually not the one who comes out."

"So it would not help to debrief one of the alters if it were Todd who went into a restraint," Eileen stated for clarity.

"Exactly. Todd and Pete are usually the ones who go into a restraint. They almost always have to be heavily sedated at the time and are quite groggy when they come out of the restraint, if they are the ones to wake up. So again, that is not the ideal time for a debriefing or even a defusing," Susannah clarified.

"What about physical restraint?" Steve asked.

"We do takedowns, when we have to. We strongly try to avoid them. Basket holds . . . therapeutic holds are used when absolutely necessary to prevent injury or to try to keep them from escalating into a mechanical restraint. Ace-down restraint is never, under any circumstances, to be used."

Susannah knew it really wasn't necessary to tell them that physical restraints such as basket holds, where a patient is held from behind as a staff member grasps their wrists, and crosses the patient's arms across his or her chest and then brings the patient to a seated position by stepping back and riding the patient down along the staff member's thigh is considered good practice. She also knew it was unnecessary to tell them that the ace-down restraint that would put the patient face down on the ground with staff on top or along side him or her was not. However, Susannah wanted to make sure to be very clear on this subject and leave no room for interpretation.

Susannah continued. "As far as chemical restraint goes, that is our primary way of keeping Todd safe when he escalates beyond being able to gain control on his own. Because of his fragile physical condition, we can't wait as long as I would like before medicating him. If we can't gain access to the NG tube or he needs to calm immediately we will us an IM, unless he's on an IV or has a hep lock in. You have to be extremely careful with noting the medication and dosage I order for each alter. A dose that Todd or Pete can tolerate can cause The Baby or some of the younger child alters to OD. Everything I have explained to you is available, in written form, at the nurses station, the med room, and in the staff lounge. There is a list of which meds and the dosage each alter receives. Copies of this list too are in Todd's chart, the med room, the staff lounge and the nurses station. Are there any questions regarding medication or any type of restraint?" Susannah looked around the room.

"I have one." Mark spoke up. "Are physical or mechanical restraints used on the very young alters?"

"I'm glad you brought that up," Susannah praised. "Again, when absolutely necessary, we do use physical restraints with the children. So far we have not had to put any of the children in mechanical restraints. There have been times when one of the children has have woken up from sedation or come out while the body was in a restraint. When that happens they are terrified. Many times it triggers a flashback of being tied up by the father. Even when it doesn't, they usually think it is because they were bad and are being punished. They fully expect to be beaten or abused in some way when they find themselves in a restraint. That is why it is necessary for them to be quickly assessed and, if possible, taken out of the restraint. Also, as far as physical restraints go, you will find that the children have much less strength than Todd or the adult alters. We need far less staff to put them in a hold. Sometimes one person can hold their legs while another holds their arms and torso. At most you we usually need three if they start head butting. Sam and Kevin have each been able to contain Timmy and Andy, at times. Are there any more questions in regard to restraints?" Susannah asked.

This time they all shook their heads no.

"All right then, let's move on." Susannah checked her notes. "One of the abuses the father did with them was to make them get down on the floor, like an animal, and lick up anything that spilled. This includes urine, feces and vomit. Some of them will immediately go into a flashback if there is any kind of accident and attempt to lick it up. Todd is included in this. If anything gets on the floor, whoever is out is to immediately be put in a hold until the mess is cleaned up. Many times they will calm once that happens."

Susannah paused while notes were taken. "I want to cover another few things and then I will let you go. Thomas has a tendency to lash out and hit some of the other alters, especially if they say anything negative about the mother. As I told you, he is extremely protective of her. He also needs to be very carefully monitored. He is one of the alters who feels no pain. He also needs to be observed for any physical problems that normally cause pain that he might not be aware of. They are all to be carefully observed for seizure activity. The upside about Thomas is that he is one of the only children who tolerate medical procedures. With the exception of not wanting a tongue depressor used on him, he has shown no fear, so far, of any medical procedure. Tom, Timmy Andy and the other child alters have to be held down, for just about anything."

"I noticed you have a crash cart on the unit," Mark observed.

"Yes. Because of Todd's medical conditions and thanks to funding by his sister, we have the necessary equipment to keep Todd going until we can transport him to the ER, should he have a medical emergency. I would like all of you to familiarize yourselves with all of the equipment we have here. Also, even though you are all certified in CPR, without having used it in a while you may be rusty. There are classes here at the hospital. For those of you who might not feel comfortable with your skills in CPR, I suggest you attend one of those classes."

Susannah once again referred to her notes and then went on. "I just want to give you information on some of the other alters and then we will take a break. These alters are basically and example of what we usually refer to as 'a layering phenomenon.' They are all related to this specific trauma. Rocky . . . Rocky, though the antagonist in the system is, in part a variation of the internal persecutor. Rocky's job in the system is to preserve the image of the good father. He blames Todd and the alters for all punishment and holds the father responsible for none. He will lash out at the alters and at Todd. As you have read, he has done some serious damage to the body. As for the twins, none of them come out very often. Their main job is to handle the feelings of abandonment and feelings triggered by being rejected by the mother when they found her after she had abandoned them the first time. The girls were the ones to return to the father after Todd ran off to the summer home his mother and stepfather had. He was rejected by the stepfather and sent back to the father by their mother. Lisa and Sarah were severely physically and sexually abused, almost to the point of death, after Peter got them back home. He kept them locked in the basement. They were kept on the floor, naked, with no food and little water for approximately a week. The mother sending Todd back was apparently one of the most traumatic events in Todd's young life. Between the day before and the day he was sent back, Todd split into seven alters that we know of."

"Do Lisa and Sarah liked to be treated as girls?" Eileen asked.

"Oh, yes." Susannah smiled at the memory of them. "You will notice a softness about them. They both like to play with what they consider girls' toys. Sarah likes to be told she's pretty. Lisa is overly concerned, to the point of obsession, with being polite and saying and doing exactly the right thing. Sarah is much more open and easy going. Lisa usually censors her if she starts divulging too much. They are both amazing artists. In fact, when you get a chance, you should all go to the art room and to my office to see some of the alters' work. You will see what incredible talent they have."

Susannah could see that they had all taken in about as much information as they could absorb for now. Even though they were professionals, they were still human. Hearing all of this at one time was getting to them. "I just need another few minutes of your time and then you can all take a long break before Todd comes back to his room. Some of the alters don't come out very often. I still want to bring to your attention some of the more important things you need to know about them. There is Bad Boy. I believe he was a fragment. Unfortunately, he quickly developed more of a personality when he started interacting with us. He is moderately psychotic. He hallucinates lighting matches and burning his hand with various types of fire. He expects to be burned and will ask for it. Willie and Peep are very psychotic. They spent long hours, possibly days at a time, locked in a trunk filled with old clothes. The isolation took its toll. The adults don't come out very often. Carol, Goodone and Miss Perkins do not like to leave their children unattended. If Miss Perkins does come out, there are to be no physical expectations placed on her. Physically, she feels like an older woman, complete with many aches and pains. Rodd ages along with Todd. He handles Todd's sexuality. He believes he has this wonderful family waiting for him to complete his job of helping Todd. He is very well read. His interests range from opera to art and literature and he is fluent in Italian. If he should come out he will most likely want to see Téa. He has never exhibited any behavioral problems."

Susannah took a deep breath and closed the folder she had on her lap. "Well, I think I have covered everything I wanted to go over for now. There are other alters, as you can see by the progress notes, but I think we have covered all we need to for now. Are there any questions?"

No one seemed to have any.

"Fine, now why don't you all take a break. Todd should be coming back here in about ninety minutes. He was heavily sedated this morning and should still be pretty groggy when he arrives. If he is able to comprehend it, I will introduce you. I would also like to introduce you to his family as they get here."

As they all dispersed, Frank and Susannah looked at each other. "That went pretty well," Frank observed.

"Yes, it did." Susannah smiled. "I'm sure they are all wondering what the Hell they have gotten themselves into right about now," she joked.

"Yeah, but once it's absorbed and they get to know Todd and the alters you won't be able to tear them away from here," Frank stated seriously.

Susannah patted his arm. "Did you have a good day with your boys?"

"The best. This whole business really makes you appreciate what you've got."

Susannah nodded in agreement and then said, "I'm going to go see how our boy is doing."

Frank headed for a break and Susannah for the ICU.

*****

Téa wanted to be in her office by six that morning. Most of her clients could not afford to lose time from work, so she had three appointments scheduled before eight-thirty. She needed to take care of some paperwork and then go to the courthouse to file some of those papers. Sam had called earlier and told her about Todd having had another seizure. When Téa called the hospital, she was told Todd had been heavily sedated and was still sleeping. She was also told that as things now stood, he would still be transferred back to psychiatry around three. Téa was so afraid for him. She realized that there must have been a serious problem if they had sedated him enough to put him out. She decided she would have time to go home, take a nap and shower before heading to the hospital to be there when the transfer took place. She also wanted to fill Sam and Viki in on her visit with Starr.

On her way to the office, Téa had stopped by the diner. Carlotta was just setting up for the day. As soon as Carlotta saw Téa's eyes, she saw that some of the light had come back into them.

"You're an early bird this morning," Carlotta pointed out and smiled.

"I have three clients all coming in before nine," Téa responded.

"I am so proud of you. Everyone talks about how much good you are doing for the community. You come up against the big boys and win every time." Carlotta's eyes shone with admiration.

"I wish life were as easy for me as law. At least in court I know what I'm doing," Téa replied with a smile.

Carlotta lifted Téa's face to her. "Mija, what has changed? I see more light in those eyes."

Téa reached up and took Carlotta's hand. She squeezed it gently. "I was able to visit with Starr yesterday. You should see her. She is the most beautiful little girl and she is already smarter than Todd, Blair, and I put together. Blair is going to let me continue to have visits with her."

Carlotta smiled. "I am so happy for you. The next time you are going for a visit let me know and I will bake some cookies for her," Carlotta offered.

"Thank you. I'll do that," Téa answered.

"There is more to it than that. I know my Téa and there is more to the light in your eyes than seeing Starr."

Téa was touched by how well Carlotta knew her. "I have finally reclaimed my place in Todd's life. He has given permission for me to visit two of the child alters and Todd himself opened up to me, it was only for a few minutes and then he retreated, but he held me. He knew it was me and he held me." Téa filled Carlotta in on the rest.

Carlotta's face filled with sadness for Todd. She shook her head and stated, "Ese pobre muchacho. Téa I'm sorry. Todd did not need having seizures on top of everything else. Will he be all right?"

Téa's eyes filled with tears. "Yes, I know he will. He needs to take an anticonvulsant, possibly for the rest of his life, but Doctor Hanen and his neurologist say that epileptics can do almost everything anyone else does."

"So why the tears?" Carlotta dapped at Téa's wet cheeks with a paper napkin.

"It is my fault that Todd has become epileptic. They found some scar tissue in his temporal lobe. It's from an old brain injury." Carlotta's expression was questioning. She did not understand. "I hit him, Carlotta. Don't you remember? When he held me in the shed. I hit him with a shovel and knocked him unconscious. That has to be the injury that caused this."

Carlotta put her arm around Téa's petite shoulders. "Let's go sit in one of the booths and talk."

"I have to get to the office," Téa protested.

"Just give me a few minutes," Carlotta responded softly. Téa allowed herself to be walked to a booth. "Did the doctors say for certain that it was that blow to the head that caused Todd's epilepsy?" Carlotta pressed.

"No, they can't pinpoint it to any specific head injury. Todd has had many."

"But you are so sure that this was the one that did it," Carlotta stated.

"I hit him hard. I used every ounce of strength I had, which was a lot because I was so furious with him."

"Why were you so furious with him?"

Téa looked at Carlotta. She could not understanding how she could ask that. "You know what Todd did to me. He made me believe we were all in danger of dying because of the explosives. He dragged me to my car. He punched me in the face, hard enough to knock me out. He tied me up. He left me tied up and then left the shed. For food, yes, but he didn't tell me that. I thought he just left me there. By the time I tricked him into untying me, I was so frightened and angry I couldn't even see straight."

"Do you think you were wrong to be so angry with him for all that?"

Téa shivered. Some of the terror she had known that night came back to haunt her. She wondered if this was what the Post Traumatic Stress Disorder Todd experienced felt like. She realized that she still wasn't completely over that long ago night. "No. He abused me. I had a right to be angry with him. I had a right to want to hurt him back, but more violence wasn't the answer."

"Were you still afraid of what he would do to you at the time you hit him?" Carlotta asked.

Téa thought for a moment. "Yes, he was completely out of control. I didn't understand why at the time. I didn't know how sick he was."

"Téa, don't you see? Just the way Todd lashed out because he was traumatized so did you. You weren't just angry, you were afraid. Even if you knew then that Todd was that mentally ill, you could not have stood by and allowed him to continue to abuse you." Carlotta could see that Téa was still burdened with guilt.

"Mija, you are a strong woman. You are not the kind to allow yourself to be abused. Your love for Todd was so strong that you put up with things from him that you never would have taken from anyone else. I think a part of you did realize you were dealing with someone who was very ill."

"You think that is why I allowed myself to be abused?" Téa was still trying to understand the part of her that allowed that.

"Yes, much in the same way I put up with Eli's bad behavior in the beginning. You were able to look past the behavior and see the good inside and feel the love, even when Todd couldn't show it. I think that your putting up with the kind of abusive treatment Todd sometimes showed you, proves that you were strong enough to hang in there, not weak. Then, when you felt you tried your best and it got out of hand, you fought back, again, out of strength. That is nothing to feel guilty about. Illness may explain the way Todd treated you but it doesn't excuse it. No matter how sick he is, that doesn't mean you have to put up with abuse."

Téa knew Carlotta was right and did feel a little better. Although feelings of guilt still persisted, Téa really did feel better. She knew that it was not in her to play the victim and that it was in her nature to fight back. She still wished that she could take that whole night back. Téa kissed Carlotta. "Do Christian, Antonio and Eli realize how lucky they are to have you for a mother?"

"If they don't, I remind them," Carlotta kidded. She stroked Téa's head. "You have me too, Mija. Don't ever forget that."

Téa hugged Carlotta and headed for her office and later to the courthouse, to take care of business. She then headed to her hotel for that nap and shower.

*****

Téa slept for almost two hours. She awoke feeling refreshed. She went to shower. Téa was in her robe, blow-drying her hair, when she thought she heard knocking on her door. Téa turned off the dryer. She was able to hear the knocking clearly now. "Who is it?" she called out.

"Kevin," she heard the voice say. He didn't sound quite right. Téa pulled her robe tightly closed and opened the door.

"I was just in the neighborhood," Kevin used his familiar excuse. He laughed as he said it.

"Kevin, you're drunk. What the Hell is going on with you?"

"Do you mean besides discovering I am the lowest piece of shit walking?"

"Did something happen with Todd?" Téa became frightened.

"Do you know that Lee Ann has a boyfriend? She does. I'll bet my kid calls him Daddy. You of all people know how hard Todd fought for his kid. Me . . . I just let mine go. Now I've got a shot at making a difference in a kid's life. You know I'm gonna blow it."

Téa was having a hard time following. "Are you talking about Timmy? Did something happen with Timmy?"

Kevin plopped down on the couch. He put his feet up. "Not yet, but give me time. Do you think River ever wonders why I'm not in his life anymore? What about Starr?"

"Starr asked about you. I told her you love her very much and still want to see her. In fact, she wants to get together with you, Sam and Viki, if Blair will allow it. Starr has so much love in her. She is being so mature about everything. We could all take a lesson from her." Téa was in awe of Starr.

"She's that way because Todd was there for her. She had a wonderful father she could depend on all her life. Do you think my son is faring as well? No matter how many men Lee Ann brings into her life, Duke will always know his dad didn't fight for him. Look at Drew. Look how he turned out without a father's guidance. Is it becoming a Buchanan trait to fuck up your kid?" Kevin asked bitterly.

Téa still did not understand Kevin's ramblings. "Kevin, did something happen at the hospital? Was there a problem with Todd or one of the alters? They told me Todd had another seizure last night and that he had to be heavily sedated this morning."

"Yeah, he had a psychotic episode. That Saber came out and tortured Todd."

"Oh God! Did he hurt him?"

"No, don't worry. They're taking all kinds of precautions." Kevin laughed to himself. "All except Kevin precautions. In fact," Kevin drew out the word fact. "Susannah thinks that I should also be a part of Todd's life when he knows it and she is going to tell him that I have been a part of his life and therapy and ask him to give his permission for me to visit Timmy. How well do you think that's going to go over?"